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Neglect and Serious Case Reviews 56 what it was like to be a child in this family: agency involvement: learning: The mother’s capacity to care for the children had decreased with each new birth, and she became increasingly emotionally detached from her children. Basic needs were poorly met, and the children often went hungry, had no bed linen, and hardly any toys. The lack of supervision, the squalor, frequent house moves and, above all, the mother’s alcohol intake must have made all the children’s lives very bewildering and distressing. Over time a large number of social workers and family support workers had been involved with the family, and concerns over the care of the children had been voiced by health visitors, police, a nursery assistant, a school nurse/ school staff and neighbours. Following a domestic violence incident, police were concerned about the conditions in which the children were living, and subsequently a child protection enquiry was initiated and a core assessment undertaken. All the children ultimately became the subject of a plan for emotional abuse and neglect. Initially the mother was noted to be making an effort to cooperate and to attend appointments with social workers, however her engagement became increasingly sporadic and unsatisfactory. Health appointments for the children were not kept, including for spectacles, dental care, and speech and language therapy. These specialist services responded by closing the case instead of treating non-attendance as a warning sign, triggering greater vigilance. The oldest two children were at primary school, where repeated absences, dirty clothing and hunger were noted but the information was not always passed through to children’s social care in a timely manner. Chloe attended nursery, where health visitor concerns about an injury to the child were discussed and passed on to the mother, but not to children’s services. Chloe was noted to play happily at nursery, as were her siblings at school, and the clean and stimulating play environment provided predictability and a respite from the chaos and lack of play facilities at home. Themes emerging from the serious case review included: • drift: At one point, there was no social worker allocated at all and concerns reported by other agencies were not responded to. Assessments were often not completed and there were recording gaps in the CSC files. There was no sense of urgency regarding this family even when heightened concerns resulted in a child protection plan for all the children. Key staff rarely attended core group meetings and tasks were undertaken by a social work assistant rather than
themeS aNd learNiNg poiNtS ‘an accident waiting to happen’ 3. A thematic analysis of neglect a qualified and experienced social worker. There was confusion and delay in responding to the threat of homelessness, and the critical housing issues that the family faced. Even after this tragic accident, this sense of lack of urgency continued, and a year passed without any formal multi-agency review of progress in safeguarding the surviving children. This practice was set within a broader context of overwhelming workload, high staff turnover and vacancy rates alongside high numbers of unallocated cases. • tolerance by professionals of dangerous conditions and poor care: The older siblings had been described as ‘happy and playful’ despite smelling of urine, glasses frequently missing or broken, minor illnesses, and school absences. This sense that the children were happy seems to have allowed agencies to avoid action. This was combined with a professional tolerance of extremely poor, cramped and unsafe living conditions. The children’s welfare was thought to be ‘good enough’ and the mother considered to be ‘just about’ coping without any clear sense of what this meant in relation to the children’s development or immediate safety. ‘An accident waiting to happen’ was the way that many of these cases were described. The overview reports for this group of serious case reviews often conclude that ‘noone could have predicted the chain of events leading to (the child’s) death’. While the precise circumstances of these accidents were often unpredictable, the reports do convey the sense that the risk of accidental harm from some source was high, due to either the precarious living conditions and/or the inadequate level of supervision from the caregiver. Deprivation and unsafe care provided a dangerous environment for these children as one overview report noted: ‘Children from deprived backgrounds are at a much higher risk of accidents than those from better off households – 13 times more likely to die from accidental injuries and 37 times more likely to die because of smoke, fire or flames’ (Staying Safe: a consultation document: DCSF, 2007). Many reports commented on chaotic living conditions, and unsuitable housing, which in at least one case included inappropriate and dangerous temporary accommodation for the family, which posed a particular fire risk. High rise accommodation created problems regarding lack of play facilities, and supervision of children ‘playing out’ in the communal areas, or in the street. There was often a sense of a lack of boundaries; both in the physical sense of inadequate fences and gates, but also in relation to what the children were allowed to do, and the times they were allowed to stay out until. There were serious case reviews undertaken where young children were playing unsupervised 57
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Neglect aNd SeriouS caSe reviewS A
Page 3 and 4:
Contents Executive Summary 7 1. The
Page 5 and 6: tableS Tables and Figures appeNdix
Page 7 and 8: iNtroductioN Key fiNdiNgS Executive
Page 9 and 10: fiNdiNgS how ofteN iS Neglect evide
Page 11 and 12: Neglect iN all ScrS from 2009-11 To
Page 13 and 14: Sudden unexpected deaths in infancy
Page 15 and 16: maintaining a healthy, safe relatio
Page 17 and 18: 1. The context of neglect and serio
Page 19 and 20: Summary 1. The context of neglect a
Page 21 and 22: 2.2 reSultS 2. Neglect in the lives
Page 23 and 24: There are encouraging signs of a dr
Page 25 and 26: figure 2.1: age distribution of chi
Page 27 and 28: 2. Neglect in the lives of children
Page 31 and 32: what did Neglect co-exiSt with? 2.
Page 35 and 36: figure 2.2: incidence of cp plan fo
Page 37 and 38: Summary 2. Neglect in the lives of
Page 39 and 40: what did Neglect coexiSt with? 2. N
Page 41 and 42: 3. A thematic analysis of neglect h
Page 43 and 44: As discussed in Chapter 2, it was n
Page 45 and 46: • There had been a lack of proper
Page 47 and 48: In reading the set of serious case
Page 49 and 50: The SCRs drew our attention to undu
Page 51 and 52: or more of a burden to his mother,
Page 53 and 54: parental learning disability Parent
Page 55: event prompting the serious case re
Page 59 and 60: 3.5 SuddeN uNexpected death iN iNfa
Page 61 and 62: agency involvement: learning: There
Page 63 and 64: Sudi riSKS aNd targeted iNterveNtio
Page 65 and 66: event prompting the Serious case re
Page 67 and 68: learning: themeS aNd learNiNg poiNt
Page 69 and 70: uising and rough handling An unders
Page 71 and 72: event prompting the Serious case re
Page 73 and 74: themeS aNd learNiNg poiNtS the long
Page 75 and 76: situation or dangers posed by, for
Page 77 and 78: Sudden unexpected deaths in infancy
Page 79 and 80: 4 Implications for policy and pract
Page 81 and 82: maiNtaiNiNg a healthy, Safe relatio
Page 83 and 84: Bibliography Blair, P., Sidebotham,
Page 85 and 86: Bibliography Ofsted (2008) Learning
Page 87 and 88: Appendix Table A.2 Category of abus
Page 89 and 90: 3. extreme Neglect / deprivatioNal
Page 92: Photography by Jon Challicom, posed
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